Systematic Review

Evidence-Based Status of Microfracture Technique:

A Systematic Review of Level I and II Studies
Deepak Goyal, M.B.B.S., M.S.(Orthop), D.N.B.(Orthop), M.N.A.M.S.,
Sohrab Keyhani, M.D.,
Eng Hin Lee, M.D., F.R.C.S.C., F.R.C.S.(Edin), F.R.C.S.(Glasg), F.A.M.S., and
James Hoi Po Hui, M.D., F.R.C.S.(Edin)

Purpose: Although many newer cartilage repair techniques have evolved over the past 2 decades, microfracture is still
being advocated as the rst line of treatment. Therefore it is timely to conduct a comprehensive review of the literature to
assess and report on the current status of Level I and II evidence studies related to microfracture techniques. Methods: A
literature search was carried out for Level I and II evidence studies on cartilage repair using the PubMed database. All the
studies that dealt with microfracture techniques were selected. Results: Fifteen studies that involved microfracture
techniques met the inclusion criteria of this review article, with 6 long-term and 9 short-term studies. These studies
compared the clinical outcomes of microfracture with those of other treatments such as autologous chondrocyte
implantation and osteochondral cylinder transfers. The majority of the studies reported poor clinical outcomes, whereas 2
studies reported the absence of any signicant difference in the results. Small-sized lesions and younger patients showed
good results in the short-term. However, osteoarthritis and treatment failures were observed at later postoperative periods
of 5 to 10 years. Conclusions: The use of microfracture for the treatment of small lesions in patients with low post-
operative demands was observed to result in good clinical outcomes at short-term follow-up. Beyond 5 years post-
operatively, treatment failure after microfracture could be expected regardless of lesion size. Younger patients showed
better clinical outcomes. Level of Evidence: Level II, systematic review of Level I and II studies.

autologous chondrocyte implantation (MACI),6,7,9 scaffold-

I t has been well established that once damaged, carti-
lage does not heal.1,2 However, in the past 2 decades,
we have seen many new modalities of treatment for
which varying degrees of cartilage repair have been re-
ported.3-38 These methods include marrow stimulation
techniques,3,7,11,13-17,19-22,24,28-32,34 osteochondral cylin-
der transfer (OCT) techniques,8,9,11,13-18,24 autologous
chondrocyte implantation (ACI),6-10,12,19-32,34,36-38 auto-
logous matrix-induced chondrogenesis, membrane-based
From Saumya Orthocare: Centre for Advanced Surgeries of the Knee Joint
(D.G.), Ahmedabad, India; Akhtar Hospital, Shahid Beheshti University of
Medical Science (S.K.), Tehran, Iran; and the Department of Orthopaedic
Surgery, National University of Singapore (E.H.L., J.H.P.H.), Singapore,
Singapore.
The authors report that they have no conicts of interest in the authorship
and publication of this article.
Received January 23, 2013; accepted May 28, 2013.
Address correspondence to Deepak Goyal, M.B.B.S., M.S.(Orthop),
D.N.B.(Orthop), M.N.A.M.S., Saumya Orthocare: Centre for Advanced
Surgeries of the Knee Joint, 210 Baronet, Sabarmati, Ahmedabad, GU
380005, India. E-mail: deepak@knee.in
2013 by the Arthroscopy Association of North America
0749-8063/1377/$36.00
http://dx.doi.org/10.1016/j.arthro.2013.05.027
based treatments,21,22 and stem cellebased cartilage
repair.35 Some of the modalities result in brocartilage
formation, whereas others result in the formation of
hyaline or hyaline-like cartilage. The progress of carti-
lage science has been quite rapid in the past decade, but
consistent, favorable, and reproducible clinical results
are still not readily available. The majority of the studies
have been case series with a low level of evidence and
few Level I and II studies.
Microfracture (MF) involves the creation of perfora-
tions 3 to 4 mm apart in the subchondral bone to release
bone marrow elements, which include stem cells and
growth factors, into the defect, which would form a clot
and induce cartilage repair.3 It has been widely performed
in patients since 19984 but has been progressively
replaced by newer treatments such as OCT, ACI, autolo-
gous chondrocyte implantation using characterized
chondrocytes (CCI), and MACI in recent years. A
comprehensive analysis of the durability and type of
repair tissue afforded by MF treatment would be useful in
providing a balanced view of the strengths and weak-
nesses of this technically simple, inexpensive rst-line
treatment5; which is currently the preferred choice of

Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 29, No 9 (September), 2013: pp 1579-1588 1579
1580 D. GOYAL ET AL.

many orthopaedic surgeons. Our purpose was to review criteria were case series, personal opinions, and
the current evidence-based status of MF technique based systematic reviews involving studies with Level III, IV,
on Level I or II evidence studies. and V evidence. A owchart describing the selection
process of the studies is given in Fig 1.

Methods
A literature search was carried out in November 2012
using the PubMed database with the following
keywords: microfracture, cartilage repair, mosaicplasty,
osteochondral autograft, osteochondral plugs, osteo-
articular transfer system (OATS), autologous matrix
induced chondrogenesis, autologous chondrocyte
implantation, untreated cartilage lesions, stem cells,
mesenchymal stem cells, and membrane seeded autol-
ogous chondrocyte implantation. The lters used
during the search were as follows: published in the past
10 years, humans, clinical trial phase I, clinical trial
phase II, randomized controlled trials, prospective
cohort studies, meta-analysis, systematic reviews, and
English (language). A total of 34 studies related to
cartilage repair with Level I and Level II evidence were
identied,5-38 as declared by the journal in which the
article was published. The search was further rened to
select only those studies that used marrow stimulation
techniques as the primary treatment or for comparative
analysis with some other modalities of cartilage repair.
The search for Level I and II studies related to marrow
stimulation techniques resulted in the selection of 18
studies.7,11,13-17,19-22,24,28-32,34 These studies compared
marrow stimulation techniques with new techniques
such as ACI,19,20,24,28-32 OCT,11,13-17,24 MACI,7,34 and
scaffold-based ACI21,22 (Table 1). There was one study
that dealt exclusively with osteochondritis dissecans
(OCD).16 Another study used abrasion as the type of
marrow stimulation procedure,34 and the study by
Gobbi et al.11 was the only study dealing with MF in the
ankle. Because these 3 studies were heterogeneous
compared with the main group,11,16,34 all 3 were
excluded. The inclusion criterion was a study on the MF
technique with Level I and II evidence. Exclusion
Results
This systematic review is based on 15 stu-
dies7,13-15,17,19-22,24,28-32 (Table 2). There were 2 Level I
or II studies that dealt with a systematic analysis of the
literature,5,33 only one of which dealt with marrow
stimulation techniques.5 This systematic review study
was used as a comparison study.
Of the 15 short-listed studies, 6 followed MF
cases for a long term14,19,21,22,24,32 whereas 9 had
a short duration of follow-up, ranging from 6 months to
3 years.7,13,15,17,20,28-31 Twelve studies dealt with
smaller cartilage lesions,13-15,17,21,22,24,28-32 whereas 3
studies dealt with large chondral lesions.7,19,20 Four
studies involved athletes.14,15,17,21 Four studies scruti-
nized the onset of osteoarthritic changes on follow-up
radiographs.14,15,19,20 Eleven studies reported failure
rates.7,14,15,17,19,20,22,24,28,29,32
There were 4 different long-term cohort studies
(Gudas et al.,13-17 Knutsen et al.,19,20 Kon et al.,21,22 and
Saris and colleagues28,29,32) that compared MF treatment
with other modalities. Gudas et al. investigated the
outcome against OATS treatment for young athletes
over a period of 3 years15,17 and 10 years,14 whereas
Saris and colleagues compared the effect of treating
cartilage defects with MF versus CCI at 1.5 years,28 3
years,29 and 5 years.32 Kon et al. reported the outcome
of defects treated with MF versus Hyalograft C up to 5
years22 and 7.5 years21 postoperatively, and Knutsen
et al. analyzed the difference between MF and ACI
treatments at 2 years20 and 5 years.19
Discussion
This systematic review is based on 15 Level I or II
evidence studies.7,13-15,17,19-22,24,28-32 The results of

Table 1. Therapeutic Cartilage Studies Comparing MF With Other Techniques of Cartilage Repair (Level of Evidence I and II)

MF v OCT MF v P-ACI MF v C-ACI MF v MACI MF v Scaffold ACI MF v CCI

Level Study Level Study Level Study Level Study Level Study Level Study
I Gudas et al.,15 2005 II Knutsen et al.,20 d d I Basad et al.,7 II Kon et al.,22 I Saris et al.,28 2008
2004 2010 2009
II Gudas et al.,17 2006 I Knutsen et al.,19 I Visna et al.,34 II Kon et al.,21 I Saris et al.,29 2009
2007 2004 2011
I Gobbi et al.,11 2006 I Vanlauwe et al.,32 2011
I Gudas et al.,16 2009 II Van Assche et al.,31 2009
I Gudas et al.,14 2012 II Van Assche et al.,30 2010
II Gudas et al.,13 2013
II Lim et al.,24 2012 Lim et al.,24
2012
C-ACI, autologous chondrocyte implantation using collagen membrane; CCI, ACI using characterized chondrocytes; MACI, membrane-based
autologous chondrocyte implantation; MF, microfracture; OCT, osteochondral cylinder transfer techniques; P-ACI, autologous chondrocyte
implantation using periosteum.
 MICROFRACTURE TECHNIQUE: EVIDENCE-BASED STATUS
Fig 1. Flowchart of articles during
selection process. (OCD, osteochondritis
dissecans.)
these studies were compared with the study of Mag-
nussen et al.,5 which was a systematic analysis of
various cartilage studies.
The great heterogeneity in patient selection, indica-
tions, scoring of the defects, scoring of the results,
period of follow-up, and technique of surgery led to
difculties in comparing the results of the various
studies. However, at the same time, the availability of
long-term studies comparing MF against OCT or ACI
treatments enabled a more thorough analysis of the
treatment outcomes. The effect of MF based on lesion
size, patients activity level, formation of osteoarthritis,
and failure rates could facilitate a better understanding
of the result of MF in the repair of the cartilage
defects.
The earliest follow-up after MF of small lesions sized 1
to 5 cm2 was performed at 6 months and 2 years by Van
Assche et al.,30,31 and 17 of 26 patients showed signif-
icant improvements in functional performance. Fifty
percent of the patients showed a nearly normal to
normal functional performance at 2 years.30 In the
same set of patients, better functional outcome was
noted with postoperative low-load activities.31 MF
treatment performed by Lim et al.,24 Saris et al.,28,29
and Vanlauwe et al.32 in nonathletic adults with small
lesions showed statistically signicant improvements in
clinical outcome scores at 3 years postoperatively. MF
performed on small cartilage lesions of nonathletic
adults with associated anterior cruciate ligament
injuries by Gudas et al.13 enabled a mean time to return
to previous activity levels within 11 months, with
improved International Knee Documentation Com-
mittee (IKDC) and Tegner scores at 3 years after MF.
Knutsen et al.20 reported that lesions smaller than 4
cm2 were found to respond better to MF in the rst 2
years. The outcome of these several studies on small
lesions treated with MF followed by low postoperative
demands has shown good short-term results.
1581
The effect of MF treatment on small cartilage
lesions that measured 1 to 4 cm2 and 1 to 5 cm2 in
high-performance soccer and sports athletes was studied
by Gudas et al.14,15,17 and Kon et al.,21 with follow-up
periods of up to 10 years14 and 7.5 years,21 respectively.
Twenty percent of athletes aged 16 to 60 years regis-
tered a reduced sports activity level despite signicant
improvements in IKDC scores from 2 to 7.5 years after
MF.21 In contrast, 52% of younger athletes aged 24

6.5 years resumed their sports activities 3 years after MF
treatment.15,17 A follow-up by Gudas et al. at 10 years
showed signicant clinical improvements in Tegner and
International Cartilage Repair Society (ICRS) scores, but
only 37% of the patients were able to maintain the
same physical activity level.14 Although complete defect
lling and tissue integration were observed in 35% of
the patients, the percentage of failures increased from
31% at 3 years15 to 38% at 10 years.14 Gudas et al.14,15
also noted that patients who received MF for small
lesions when aged less than 30 years had better Tegner
and ICRS outcomes than older patients. The long-term
results thus show an increasing failure trend in small
lesions with high postoperative demands. However,
patients belonging to the younger age group showed
comparatively better long-term outcomes.
The treatment of large lesions measuring 2 to 10 cm2
and 4 to 10 cm2 was documented by Knutsen et al.19,20
and Basad et al.7 respectively. Various scoring systems
were used and signicant improvements in clinical
outcome scores were noted up to 5 years after MF
compared with pretreatment status. Tegner scores were
found to be signicantly improved in the rst,7 second7
and fth year19 after MF treatment. However, there
were conicting Lysholm scores. Basad et al. reported
a broad scattering of results at 2 years, whereas Knutsen
et al.20 showed signicantly better scores at 1 year
compared with baseline, which remained signicantly
improved when checked at 2 years20 and 5 years19 after
Table 2. Comparison of Level I and II Studies Related to MF

1582
Van Van
Saris Saris Vanlauwe Kon Kon Knutsen Knutsen Basad Assche Assche Gudas Gudas Gudas Gudas Lim
et al.,29 et al.,28 et al.,32 et al.,21 et al.,22 et al.,20 et al.,19 et al.,7 et al.,30 et al.,31 et al.,15 et al.,17 et al.,14 et al.,13 et al.,24
2009 2008 2011 2011 2009 2004 2007 2010 2010 2009 2005 2006 2012 2013 2012
Type of study MF with MF with MF with MF with MF with MF with MF with MF with MF with MF with MF with MF with MF with MF with MF with
(isolated CCI CCI CCI scaffold- scaffold- ACI ACI MACI ACI CCI OCT OCT OCT OCT OCT, ACI
technique or based ACI based ACI
comparative
technique)
Age [mean 33.9
33.9
33.9
8.6 26.5
4.5 30.6 18-45 18-45 37.5 31
8 31
8 24.3
24.3
24.3
34.1 32.9
(range)] (yr) 8.6 8.6 (18-50) (18-35) 6.8 6.8 6.8 (22-42)
(18-50) (18-50)
Sex ratio (M:F) 41/20 41/20 41/20 20/0 27/13 17/3 24/10 24/10 16/12 16/12 17/12 17/12
Duration of 1.57 yr 1.57 yr 1.57 yr 30 mo 36
36 21.32

symptoms (0-18 yr) (0-18 yr) (0-18 yr) mo 5.57 mo
[mean
(range)]
No. of patients
treated by
each

D. GOYAL ET AL.
technique
Marrow 61 61 61 20 40 40 (not 40 (not 20 34 34 29 29 29 34 30
stimulation specied) specied)
OATS 28 28 28 34 22
ACI 57 57 57 21 40 40 (not 40 (not 40 33 33 18
specied) specied)
Method of ACI CCI CCI CCI Hyalograft Hyalograft ACI ACI MACI CCI CCI ACI-P
C C
Duration of 36 18 60 24 and 90 24 and 60 12 and 24 60 6, 12, and 6, 9, 12, 12 and 12, 24, 12, 24, 124.8 36.1 (34- 80.4
follow-up 24 and 24 24 and 36 and 36 (86-132) 37) (42-126)
[mean
(range)]
(mo)
Lesion details
No. of lesions 1 1 1 1 1 1
Size of lesion 2.4
1.2 2.4
1.2 2.4
1.2 1.9
0.6 2.5
0.79 2-10 2-10 4-10 2.3
1 2.3
1 2.77
2.77
2.77
2-4 2.77
[mean (1-5) (1-5) (1-5) (1-5) 0.68 0.68 0.68 (1.2-3.6)
(range)]
(cm2)
Outerbridge III/IV III/IV
score
ICRS grade III/IV III/IV III/IV III/IV III/IV III/IV III/IV
Location of
lesion
Condyles 61 61 61 16 34 29
MFC 12 28 Yes, not Yes, not 25 23 23 23
specied specied
(continued)
Table 2. Continued

Van Van
Saris Saris Vanlauwe Kon Kon Knutsen Knutsen Basad Assche Assche Gudas Gudas Gudas Gudas Lim
et al.,29 et al.,28 et al.,32 et al.,21 et al.,22 et al.,20 et al.,19 et al.,7 et al.,30 et al.,31 et al.,15 et al.,17 et al.,14 et al.,13 et al.,24
2009 2008 2011 2011 2009 2004 2007 2010 2010 2009 2005 2006 2012 2013 2012
LFC 4 10 Yes, not Yes, not 9 6 6 7
specied specied
Patella 4 (patella-
trochlea)
Trochlea 3 2 Yes, not Yes, not
specied specied
Preoperative
score/
assessment

MICROFRACTURE TECHNIQUE: EVIDENCE-BASED STATUS

IKDC 47.3
8.5 41.1
12.3
ICRS 51 51
VAS 70.0
14.7 54 54
Modied
Cincinnati
Lysholm 55 55 55
25 51.2

6.2
Cincinnati
Sports Scale
Tegner activity 4.7
1.6 3 (median) 2 7.8
0.8 7.5 2.8
1.4
evaluation (median) (MF-
ACD) and
7.7
0.8
(MF-
OCD)
KOOS 59.46
59.53

1.98 14.95
Pooled 0
symmetry
index
ARS 8.1
5
HSS 77 77 78.22

9.12
Results
IKDC 86.8
9.7 70.2
14.7
at 24 mo, at 60 mo
79.0
11.6
at 90 mo
ICRS 76 at 12 76 at 12 73.9

mo, 75 at mo, 75 at 1.5 (MF-
24 mo, 75 24 mo, 75 OCD) and
at 36 mo at 36 mo 78.2

1.4 (MF-
ACD) at

1583
120 mo
(continued)
 1584
Table 2. Continued

Van Van
Saris Saris Vanlauwe Kon Kon Knutsen Knutsen Basad Assche Assche Gudas Gudas Gudas Gudas Lim
et al.,29 et al.,28 et al.,32 et al.,21 et al.,22 et al.,20 et al.,19 et al.,7 et al.,30 et al.,31 et al.,15 et al.,17 et al.,14 et al.,13 et al.,24
2009 2008 2011 2011 2009 2004 2007 2010 2010 2009 2005 2006 2012 2013 2012
VAS 81.8
15.0 35 at 12 25 at 60
at 24 mo, mo, 30 at mo
84.0
10.8 24 mo
at 90 mo
Modied
Cincinnati
Lysholm 78 at 12 81 at 60 82
18 85.6

mo, 75 at mo at 6 mo, 6.8
24 mo 82
22
at 12 mo,
69
26
at 24 mo
Cincinnati
Sports Scale
Tegner activity 8.5
1.6 at 6 at 24 mo, 3 at 6 mo, 6.2
0.4 6.9 5.1
1.5

D. GOYAL ET AL.
evaluation 24 mo, 6.9 5 at 60 mo 3 at 12 (MF-

1.8 at 90 mo, 3 at ACD) and
mo 24 mo 6.1
0.7
(MF-
OCD) at
120 mo
KOOS Improved 75.04
Improved
by 15.83 14.50 by 14.07


3.48 (n51) 2.54
(16.50

3.99
if onset of
symptoms
was <2 yr
and 17.09

3.77 if
onset of
symptoms
was <3
yr)
Pooled 6 at 6
symmetry mo, 1 at 9
index mo, 0 at
12 mo, 6
at 24 mo
(continued)
Table 2. Continued

Van Van
Saris Saris Vanlauwe Kon Kon Knutsen Knutsen Basad Assche Assche Gudas Gudas Gudas Gudas Lim
et al.,29 et al.,28 et al.,32 et al.,21 et al.,22 et al.,20 et al.,19 et al.,7 et al.,30 et al.,31 et al.,15 et al.,17 et al.,14 et al.,13 et al.,24
2009 2008 2011 2011 2009 2004 2007 2010 2010 2009 2005 2006 2012 2013 2012
ARS 4.8
5 at
12 mo,
5.4
5 at
24 mo
HSS 83 at 12 83 at 12 87.6

mo, 82 at mo, 82 at 4.56
24 mo, 81 24 mo, 81
at 36 mo at 36 mo

MICROFRACTURE TECHNIQUE: EVIDENCE-BASED STATUS

MRI Performed Performed Performed
at 1 yr at 10 yr at 12-14
mo
Elevation of 51.5%
subchondral
bone plate
on MRI
Subchondral 33% 28% 48%
cysts on MRI (7 of 21) (7 of 25) (14 of 29)
Joint surface 52.35% 52%
congruency (11 of 21) (11 of 21)
restored
Outerbridge I/II
grade (80% of
patients)
Histology Performed Performed Performed Performed Performed
at 1 yr at 2 yr at 5 yr at 1 yr, at 1 yr,
57% 55%
brocartil- brocartil-
age and age and
43% 45%
broelastic broelastic
tissue tissue

Complications
Periosteal
hypertrophy
Cartilage 8 (1
hypertrophy sympto-
matic)
Periosteal
hypertrophy
requiring
surgery

1585
(continued)
 1586 D. GOYAL ET AL.

ACD, articular cartilage defect; ACI, autologous chondrocyte implantation; ARS, Activity Rating Scale; CCI, ACI using characterzied chondrocytes; F, female; HSS, Hospital for Special Surgery;
KOOS, Knee Injury and Osteoarthritis Outcome Score; LFC, lateral femoral condyle; M, male; MACI, membrane-based ACI; MF, microfracture technique; MFC, medial femoral condyle; MRI,
MF. Short Form 36 (SF-36) and visual analog scale

et al.,24

12 (3)
2012
Lim (VAS) pain scores were only investigated by Knutsen
et al., but these also showed a similar pattern, whereby
signicantly better outcomes were achieved after the
et al.,13

rst year20 and lasted for 5 years after MF.19 However,

Gudas

2013

some histologic sections showed the presence of some

hyaline cartilage tissue, which correlated with the
38 (11) absence of treatment failures at 5 years.19 Knutsen
et al.,14
Gudas

2012

et al.19,20 also noted that patients aged under 30 years

with large lesions had better clinical outcomes than
older patients. Magnussen et al.5 also noted worse
27.6% (8)

3.4% (1)
et al.,17
Gudas

31 (9)
2006

outcomes of MF in larger lesions. Our review showed

that despite conicting Lysholm scores, other scoring
systems such as ICRS, Tegner, SF-36, and VAS pain
et al.,15

31 (9)
Gudas

2005

scores have shown clinical improvements that lasted for

up to 5 years.
magnetic resonance imaging; OCD, osteochondritis dissecans; OCT, osteochondral cylinder transfer techniques; VAS, visual analog scale.

The studies on MF did not mention any ndings of

osteoarthritis, except for studies by Knutsen et al.,19,20
et al.,31
Assche

2009
Van

Saris et al.,29 and Gudas et al.14,15,17 At 1 year after MF,

subchondral cysts were observed in 33% of patients
treated with MF.15 Subchondral bone elevation was
et al.,30
Assche

2010
Van

noted in 51.5% of patients at 3 years,29 and radio-

graphic evidence at the same time point after MF
showed the formation of subchondral cysts in 28% of
et al.,7
Basad

patients.17 Osteoarthritis was not detected in patients

2010

5 (1)

with large lesions at 2 years,20 but 33.3% of patients

were found to have early osteoarthritis at 5 years.19
Knutsen
et al.,19

23 (9)

Radiographic evaluation by Gudas et al. also showed

2007

that osteoarthritis was absent in patients with small

lesions at 3 years15 but was present in 48% of patients
at 10 years follow-up.14 Despite the improved clinical
Knutsen
et al.,20

2.5 (1)
2004

outcomes by MF, the percentage of patients with

osteoarthritis after MF increased with time, regardless
of lesion size. However, on the basis of these 2 follow-
et al.,22

2.5 (1)

up studies, it is unclear whether the probability of

2009
Kon

osteoarthritic debilitation is higher in large lesions

because of the different time points that were analyzed.
The occurrence of failures in non-athletes with small
et al.,21
2011

lesions differed in 2 studies: Lim et al.24 reported a 12%

Kon

failure rate at 1 year, whereas Saris et al.28 reported

a low incidence of 3.3% at 1.5 years after MF, which
Vanlauwe

increased to 11.5% by the third year.29 In large lesions

16.4 (10)
et al.,32
2011

of non-athletes, cases of failure were low, at 2.5% for

the rst 1.25 years.20 However, more failures were
discovered 5 years after MF, with rate of 23%.19 With
et al.,28

3.3 (2)

regard to the failure rates of patients with athletic

2008
Saris

careers, only data on the treatment of small lesions

were reported. Of the patients with small lesions, 31%
had failure at 3 years,15,17 with a slightly higher failure
11.5 (7)
et al.,29
2009
Saris

rate of 38% at 10 years.14 Gudas et al.14 mentioned that

Table 2. Continued

the high failure rates after MF in their study could be

accounted for by the greater physical activity levels of
brocartilage
repair tissue
Arthrobrosis

authors [%
Loosening of

their professionally athletic study population.

judged by
failure as
Treatment

(No. of
cases)]

On review of studies that performed comparative

analysis of MF with other methods, MF was reported to
result in inferior outcomes in all studies except for studies
 MICROFRACTURE TECHNIQUE: EVIDENCE-BASED STATUS
by Lim et al.24 and Knutsen et al.19,20 In comparison to
OATS treatment, patients who underwent MF had worse
IKDC scores13 and reduced sports activity levels from 3 to
10 years postoperatively.14 In studies that compared MF
against CCI, signicantly reduced ARS (Activity Rating
Scale) scores at 1 and 2 years postoperatively were only
observed in MF-treated patients. Saris et al.29 noted that
improvements in clinical outcomes of MF-treated defects
plateaued at 1.5 years and histologic outcomes were
worse compared with CCI treatment, and they
concluded that MF was inferior to CCI by 1.5 years.28
Worse Knee Injury and Osteoarthritis Outcome Scores
were observed at 3 years, which were accompanied by
subchondral bone elevation in defects subjected to the
MF.29 Treatment failure also occurred relatively earlier,
within the rst 3 years in the MF group, compared with
the CCI group.32 Defects treated with MACI yielded
better functional outcomes for defects larger than 4 cm2,7
and Kon et al.22 concluded that better repair tissue
durability was achieved with the treatment of defects
with Hyalograft C at 5 years postoperatively. Conversely,
Lim et al. did not nd OATS or ACI to be superior to MF in
terms of postoperative functional scores and magnetic
resonance imaging grades. Knutsen et al. also did not nd
any signicant difference between the histologic and
clinical results of defects treated with ACI and MF at 2
years20 and 5 years.19
Limitations
The reviewed studies lacked a proper control group
consisting of untreated cartilage lesions, as was also
mentioned in the study by Magnussen et al.5 There are
currently only 2 cohort studies comparing MF against
each of the other treatments. Multicenter prospective
trials for MF cases should be conducted with signicant
numbers of patients matched for characteristics such as
age, lesion size, prior cartilage history, activity level, and
common outcomes score, and these patients should be
randomized into various treatment groups with no
treatment as a control group. Ideally, quantitative and
qualitative assessments should be carried out for
a minimum of 10 years to specically check for corre-
lation of repair tissue to the possible inuence of factors
such as age, lesion size, and onset of osteoarthritis. Such
long-term cohort studies would enable a more
comprehensive and balanced assessment of the inferi-
ority or superiority of MF over the other newer cartilage
repair techniques such as OCT, ACI, MACI, and CCI.
Conclusions
The use of MF for the treatment of small lesions in
patients with low postoperative demands was observed
to result in good clinical outcomes at short-term follow-
up. Beyond 5 years postoperatively, treatment failure
after MF could be expected regardless of lesion size.
Younger patients showed better clinical outcomes
1587
regardless of lesion size. It is still unclear from the
currently available publications whether the newer
cartilage repair techniques such as ACI, CCI, MACI, and
OCT are superior to MF.
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